Diabetes

Why number of diabetes patients is increasing in India?

India is diabetes capital of the world with projected population 80 millions diabetic by 2030. We are exploring current scientific research , why number of diabetic patients is rising in India.

India : The diabetes capital of the world.

Current scenario

Current studies  shows that 9.1 percent of India population is diabetic. It i s more that the world average of 8.3 percent. Since we have a large population ( 1.3 billion) we have an equally large population of diabetics. In 2013, there were 65.1 million people between 20 and 79 years of age with diabetes and this number is predicted to rise to 79.4  million by 2030. So problem is not only that we have a large population base, we are getting diabetes at a rate faster than rest of the world.

The rise in incidence of diabetes cases is attribute to multiple causes which include genetics factors with contribution from environmental  causes.

Inheritance of abnormal genes are responsible for some cases of diabetes especially type 1 diabetes ( seen in young patients , usually need insulin) . Even in these patients , it is the food and other life style factors which decide the occurrence and course of disease. The type 2 diabetes ( seen in middle aged, usually obese adult which take tablets to control blood sugar) is predominantly because of environmental factors ( food and life style ).

The important question is “what exactly are these so called life style factors.”the more important issue is “what exactly should we do about that.”

Obesity

There is clear scientific evidence that the rates of obesity and type 2 diabetes are constantly increasing in India, every year and they are very much related to each other.

Studies show that Indian overweight and obesity prevalence (percent adults 24–65 with BMI≥25 kg/m2) would be expected to increase from 39% to 49% by the year 2024.  A similar pattern is been witnessed for type 2 diabetes incidence which  would rise in parallel with cases of obesity. By year 2024 there will be 319 to 336 diabetic cases per 100,000 population.

Basu S, Vellakkal S, Agrawal S, Stuckler D, Popkin B, Ebrahim S. Averting Obesity and Type 2 Diabetes in India through Sugar-Sweetened Beverage Taxation: An Economic-Epidemiologic Modeling Study. Blakely T, ed. PLoS Medicine. 2014;11(1)
Basu S, Vellakkal S, Agrawal S, Stuckler D, Popkin B, Ebrahim S. Averting Obesity and Type 2 Diabetes in India through Sugar-Sweetened Beverage Taxation: An Economic-Epidemiologic Modeling Study. Blakely T, ed. PLoS Medicine. 2014;11(1)

As compared with their western counterparts, Indian have lesser prevalence of obesity and overweight. But the incidence of diabetes is higher in Indian that what we see in western countries. It is suggested that Indian are at higher risk of developing diabetes if they are obese ( BMI > 30)  or over weight ( BMI 25-30).

 

Surprisingly , many Indians are known to have diabetes have weight with in the normal limits ( BMI < 25). So just because you are lean and young does not mean you are not at risk of having the diabetes. Even the slight gain in weight is a bad sign. The average age of an Indian  developing  diabetes  is at least a decade earlier that their western counterpart.

Some useful links

Steady urban migration

There is a steady migration of rural population to cities in search of  better living and employment  opportunities. Diabetes is reported to be about four times commoner in urban Indian  population than in their rural counterpart. More over it has a higher  incidence among the norther states than in southern states of India. 

Studies have  found that living in  urban areas  is a strong risk to develop  diabetes in India . it is explained through the lack of  physical activity  and changes in the eating habits, both associated with an urban lifestyle. 

 

In urban areas , people mostly engage in white collar professions associated with long duration of sitting or minimal physical activity. Traditional  physically vigorous jobs like agricultural work and manual labour intensive manufacturing are simply going out of fashion in a typical  Indian  urban setting.

Moreover , richer you are, minimal you work manually. Car parking has to be in basement of the building, basement has to be connected with an elevator. Staircase are usually meant for servants , cleaner and other lower order staff.

 

 Plus  the eating habits are rapidly shifting to high carbohydrate, high fat and low fiber diet, typically of what is served in any fast food restaurant. Wealthier you are , more frequent you eat outside . Now , the apps can deliver gourmet food , right on your dining table. You  save your time and also the calories , you would have burned while walking to the restaurant. 

lifestyle changes

Physical inactivity

Modern urban life style has reduced the requirement of manual labour as a precondition of employment.  Most of us has a routine  which involves little or no physical activity.  A recent report from Stanford shows that countries where people show lesser physical activity have a higher incidence of obesity and diabetes. The physical activity data for research was provided by a mobile company which recorded the steps walked by each mobile user in 170 different countries.

The question is why people live a sedentary life and do not do  the required amount of physical activity required.

Recent research has shown that often people have incorrect perception about physical activity and sedentary life style. Majority of of people have  a view that they must be active as they have a busy work schedule and a hectic life. Moreover there are certain perceived barriers which prevent people to involve in exercise. The most common ones are the lack of comfortable walking shoes, concern about their looks while doing the exercise and having other more pressing daily commitments which are given priority over the exercise.

One of the largest studies conducted by Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study, on this issue has some startling observations.

Nearly half of Indian population is physically inactive which increases risk of diabetes. It is far more common in urban areas than rural, and males are more inactive than females. What ever little physical activity males do , it is at their work place only. More than 90 percent of people do not engage in any type of sports or  recreational physical activity.  Even those who claim, that they are active, the amount of physical activity is 20 min per day which half of what is recommenced.

Current recommendation are 30 minutes of brisk walking which at the speed of 5.6 km per hours.

It is not difficult to understand why people are becoming so inactive.  The household income in urban areas is steadily rising. Larger number of people are getting jobs which are  less and less physically demanding. Almost universal access to personal  mechanized transport and household appliances among urban dwellers further contributes to this inactivity.

High fat intake

in last two decade, there is rapid shift in the dietary habits of whole of the Indian population. The oil and fat consumption is rapidly rising in our society.  The National Sample Survey Organization (NSSO) survey results indicate that the fat intake of rural Indian populations has risen one and a half folds within last one decade. The incidence of obesity and diabetes  have shown almost similar pattern.

High oil and fat consumption leads to a medical condition known as   metabolic syndrome (MS). it is refer to a constellation of metabolic abnormalities characterized by abdominal obesity( big tummy , dyslipidemia, high  blood pressure, impaired fasting glucose , and insulin resistance.

Abdominal obesity
Dyslipidemia
 High  blood pressure
Impaired fasting glucose 
Insulin resistance.

The increased fat intake is primarily because of changes eating habits of people acquiring financial prosperity. The amount of cooking oil used is  increasing and also the frequency of eating out, where the there food is usually fat rich. The shifting of cooking to sunflower based refined oil has partially been blamed for this.

High free sugar intake 

Before the Roman Emperor, Alexander the Great came to India in 327 BC, honey was the only thing they knew that could sweeten the food. Roman Emperor was pleasantly  surprised to see “” Sugar ” as another alternative to honey , and described it as a “reed that gives honey without bees” 

Not only did we  invent it , we also use it liberally. We do not know a celebration without sweets, and we have some reason to celebrate almost daily. Sugar sweetened beverages (cold drinks) is available even  in the most remote locations an Indian can reside. A 200 ml bottle of any cold drink cost around 10 rs and every body can have it.

 

Surprisingly polio vaccine is distributed free of cost. In-spite of government’s best efforts, it  never achieve more than 40-50  percent  coverage of targeted population

 On an average, every Indian drinks  11 liters of cold drinks in a year and is rising  . It is a multi-billion dollar industry , coming third after tea packaging and biscuits.

Gulati S, Misra A. Sugar Intake, Obesity, and Diabetes in India. Nutrients. 2014;6(12):5955-5974. doi:10.3390/nu6125955.

The harmful effects of excessive sugar intake are easy to understand. Excess sugar  is converted into fat, in the body, This fat gets deposited at different places in our body causing obesity, diabetes and heart attack, besides a score of other diseases.

Some useful links

Non vegetarian diet

A vegetarian diet , by definition means that it is based on plant foods such as cereals, legumes, fruits, leafy vegetables, nuts, seeds, and sea vegetables. It does not include food originating from animals , including milk and egg.

There is strong scientific evidence that vegetarian diet protects you from diabetes. It does so partly by keeping your weight and BMI down.  Vegans are also found to have lesser insulin resistance  and a better lipid profile than the non vegan . 

Studies have reported that those non-vegetarian diabetics which switch to vegetarian diet once diagnosed of diabetes , are found to have better blood sugar and lipid control, than those which continue to take non vegetarian diet. If you are taking milk, egg and fish, you have higher risk of developing diabetes than one who is pure vegan but still lower than those who are frankly non vegetarian. 

India is witnessing a nutritional transition  in which the population is shifting its dietary preferences. people are leaving the diet rich in cereals , legumes , vegetable and fruits and slowly switching to a diet rich in sugar, fat and animal origin food like milk, egg and meat.

You will be surprised to know that , from year 1975 to 1995 , the total per-capita consumption of cereals had shown a gradual reduction. In the same duration , consumption of sugar, fat and meat had dramatically risen. And so also the incidence of diabetes and obesity.

Its not difficult to explain that people are opting for a “western diet” (high intake of meat, high-fat dairy, refined grains, and fast food) . It looks like a chicken barger. 

Some useful links

Concluding:

Diabetes is nothing but the result of increasing physical inactivity and shift  to western diet rich in fat sugar and meat. We can address this issue by increasing physical activity and sticking to old fashion  Indian vegan diet.

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